Provider Demographics
NPI:1629502646
Name:PHILLIPS, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-0119
Mailing Address - Country:US
Mailing Address - Phone:330-759-9233
Mailing Address - Fax:
Practice Address - Street 1:1825 TIBBETTS WICK RD
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:OH
Practice Address - Zip Code:44420-1222
Practice Address - Country:US
Practice Address - Phone:330-759-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist